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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_953_Библиотеки_им_академика_М_И_Перельмана.pdf
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►Содержание►
FIGURE22-1Lithotomypositionforanorectalsurgery.
Adetailedexternalinspectionisperformedalongwithadigitalrectal examination,whichrevealstheextentofthefissure,hypertonicityofthe IAS,andanyassociatedsentinelskintags.AHillFergusonretractoris usedtovisualizethefullextentofthefissure,whilealsocarefully inspectingtheanalcanalforconcomitantpathologiessuchasabscess, fistula,andinflammatoryboweldisease.Onecommonfindingisa subcutaneousfistulaatthebaseofthefissure,whichmayleadtoasmall infectionwithinthesentineltag.BecauseofthespasticnatureoftheIAS, asmallormediumretractorisoftenallthatcanbesafelyinserted.
ClosedLIScanbeperformedsafelyineithertherightorleftlateral positions.Theauthorsprefertherightlateralpositiontoavoid hemorrhoid-associatedbleeding.Withgentlestretchingofthesphincter complexusingtheretractor,theexternalanalsphincter(EAS)ispulled backfromitsnaturalanatomicpositionatrestofoverlyingthedistal extentoftheinternalsphincter,andtheintersphinctericgroovecaneasily bepalpated.Ifthegrooveisnotclearlydefined,aPrattbivalveretractor
canbeusedtoplacetheIASonfurtherstretch(Fig.22-2).
FIGURE22-2Demonstrationofintersphinctericgroove
withPrattbivalveretractorusedtoplaceinternalanal sphincteronstretch.
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AscalpelisthenbroughtontothefieldforcarefulIASdivision. Althoughseveralbladesareappropriate,itisimportantthatthescalpel havealowprofiletoensureprecisemovementsandtoavoid unintentionalinjuryofthesurroundingstructures.Typically,anarrow11 bladescalpelorasimilarmini-bladesuchasabeaverorcataractbladeis used.Atailoredsphincterotomyisappropriatetoavoidpostoperative complications,withthemostproximalpointofdivisionlimitedtothe apexofthefissureratherthantothedentateline.
Thescalpelisinsertedintotheintersphinctericgroove,andadvanced
untilthetipofthebladeisuptothesamelevelastheapexofthefissure. Thesurgeon’sindexfingerisinsertedintotheanalcanaltohelpguidethe bladeandensureproperIASdivision.Thebladeisinitiallyadvancedinto thegroovewithaparallelorientation,andthenturnedtofacetheIAS. Lateraltomedialmuscledivisionusingshallowstrokescanthenbedone duringscalpelwithdrawal(Fig.22-3).
FIGURE22-3Closedlateralinternalsphincterotomy:A.
Narrowbladeplacedinintersphinctericgroove.B.Index fingerusedtoguideIASdivision.C.Lateraltomedialdivision ofIASfibers,withbladeinsertedintotheintersphincteric groove.D.MedialtolateraldivisionofIASfibers,withblade insertedintothesubmucosalspace.
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Sometimes,2–3superficialpassesofthebladearerequired.Theindex fingercanhelpdeterminewhenanadequatesphincterotomyhasbeen performed,andcanalsobeusedtofracturepartiallydividedmuscle fibersbyplacingbluntlateralpressureontheIAS.Keepingthescalpel handleparallelwiththeanalcanalratherthananglingthescalpeltip towardthecanalcanhelpavoidinjurytothesurgeon’sfingerandthe mucosaoverlyingthesphincterotomysite.
Analternativeapproachistoslidethebladeundertheanalmucosa alongtheinternalaspectoftheIAS,andthenapplypressuretowardthe EASinamedialtolateralfashion,aimingtowardtheintersphincteric groove.Carefulapplicationofpressuremustbemaintainedtoavoid injurytotheEAS.Pressureisapplieduntila“pop”isfelt,indicating successfuldivisionoftheIASonstretch.Thisapproachhaslesspotential forfingerinjury,butahigherlikelihoodofmucosalinjury.
Aftersphincterotomy,thesurgeonshouldbeabletoappreciatea releaseoftensionontheIAS.Bleedingisuncommon,butwhenitdoes occur,itusuallyresolvesafter1–2minutesoffingercompression.The anodermandrectalmucosashouldbecarefullyinspectedtoensurethat therewerenounintentionalinjuriesfromtheblade.Becauseofthe limitedsizeofthedefectintheanoderm,sutureclosureistypicallynot required.
Althoughatruefissurectomywithfullsurgicalexcisionoftheanal fissureisnotwarranted,thesurgeontypicallyaddressesachronicfissure atthetimeofLISbyexcisingtheheapedupedgesofthefissure, removingtheassociatedsentinelskintag,andcauterizingthebaseofthe fissuretohelpeliminatechronicgranulationtissue.Thefissurewoundis leftopenratherthantryingtosuturetheareaclosed.Superficialdivision ofanyassociatedfistulaissafeandappropriateatthattimeaswell.
HybridTechnique
Forsurgeonswhodesireaminimallyinvasiveapproach,butfeel uncomfortablewithblindIASdivision,ahybridtechniqueiscommonly usedthatinvolvescomponentsofbothopenandclosedLIS.This alternateapproachinvolvesthecreationofasmall,transverseincisionin
theintersphinctericgroove,typicallylessthan5mminsize.Metzenbaum scissorsorahemostatcanthenbeusedtofirstdefinetheintersphincteric space.TheinstrumentisthenshiftedmedialtotheIAStobluntlyelevate theanodermofftheIAS.TheIASisthendividedwithscissorsunder directvisualization,onescissorbladewithintheintersphinctericgroove andtheotherwithinthenewlydevelopedsubmucosalspace(Fig.22-4). Thesmalldefectintheanodermcanthenbeclosedwithasinglechromic stitch.
FIGURE22-4Hybridtechnique:A.Intersphinctericspace
isdefined;B.Internalanalsphincterissharplydividedunder directvisualization.
POSTOPERATIVEMANAGEMENT
PostoperativecareissimilarforclosedLISwhencomparedwiththatin otheroutpatientanorectalsurgeries,andincludessitzbaths,stool softeners,andscheduledibuprofenorsimilarnon-narcoticanalgesic agents.Patientstypicallyexperienceverylittleprocedure-relatedpain, andtheyoftenexperiencesignificantrelieffromtheirfissure-associated painwithin1–3days.

COMPLICATIONS

Bleeding Urinaryretention Infection Fistula Fecalincontinence
ComplicationsareuncommonafterclosedLIS,althoughtheydooccur atratessimilartotheopentechnique.Majorbleedingrequiring reoperationoccurs<2%ofthetime.Urinaryretentionisrelatively commonafteranorectalsurgery,butcanbeavoidedbylimitingsuturing anddissection,obtainingadequateanalgesia,andlimitingintravenous fluidadministration.Althoughinfectionisuncommon,itmaymanifestas purulentdrainagefromthesiteofclosedLIS.Whenamucosalinjuryis unintentionallycreated,especiallyifnotidentifiedintraoperatively,the patientcandevelopananalfistulaandabscess.Theextentofthisfistula dependsonthenatureoftheinjury,butitisusuallysubcutaneousor intersphinctericinnature.Publishedratesoffecalincontinenceare variable,butlong-termalterationsinfecalcontinenceareuncommon whenthetailoredapproachisutilized.
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